Projected environmental and public health benefits of extended-interval dosing: an analysis of pembrolizumab use in a US national health system.

BACKGROUND: Health care is a major source of greenhouse gas emissions, leading to climate change and public health harms. Changes are needed to improve the environmental sustainability of health-care practices, but such changes should not sacrifice patient outcomes or financial sustainability. Alternative dosing strategies that reduce the frequency with which specialty drugs are administered, without sacrificing patient outcomes, are an attractive possibility for improving environmental sustainability. We sought to inform environmentally sustainable cancer care by estimating and comparing the environmental and financial effects of alternative, clinically equivalent strategies for pembrolizumab administration. METHODS: We conducted a retrospective analysis using a cohort of patients from the Veterans Health Administration (VHA) in the USA who received one or more pembrolizumab doses between May 1, 2020, and Sept 30, 2022. Using baseline, real-world administration of pembrolizumab, we generated simulated pembrolizumab use data under three near-equivalent counterfactual pembrolizumab administration strategies defined by combinations of weight-based dosing, pharmacy-level vial sharing and dose rounding, and extended-interval dosing (ie, every 6 weeks). For each counterfactual dosing strategy, we estimated greenhouse gas emissions related to pembrolizumab use across the VHA cohort using a deterministic environmental impact model that estimated greenhouse gas emissions due to patient travel, drug manufacture, and medical waste as the primary outcome measure. FINDINGS: We identified 7813 veterans who received at least one dose of pembrolizumab-containing therapy in the VHA during the study period. 59 140 pembrolizumab administrations occurred in the study period, of which 46 255 (78·2%) were dosed at 200 mg every 3 weeks, 12 885 (21·8%) at 400 mg every 6 weeks, and 14 955 (25·3%) were coadministered with infusional chemotherapies. Adoption of weight-based, extended-interval pembrolizumab dosing (4 mg/kg every 6 weeks) and pharmacy-level stewardship strategies (ie, dose rounding and vial sharing) for all pembrolizumab infusions would have resulted in 24·7% fewer administration events than baseline dosing (44 533 events vs 59 140 events) and an estimated 200 metric tons less CO2 emitted per year as a result of pembrolizumab use within the VHA (650 tons vs 850 tons of CO2, a relative reduction of 24%), largely due to reductions in distance travelled by patients to receive treatment. Similar results were observed when weight-based and extended-interval dosing were applied only to pembrolizumab monotherapy and pembrolizumab in combination with oral therapies. INTERPRETATION: Alternative pembrolizumab administration strategies might have environmental advantages over the current dosing and compounding paradigms. Specialty medication dosing can be optimised for health-care spending and environmental sustainability without sacrificing clinical outcomes. FUNDING: None.

Carpal Tunnel Syndrome as a Test Case for Value Assessment During the Presurgical Period: The Impact of Structure and Processes of Care.

BACKGROUND: Few performance measures assess presurgical value (quality and utilization). OBJECTIVES: Using carpal tunnel syndrome (CTS) as a case study: (1) develop a model to evaluate presurgical quality and utilization and (2) identify opportunities for value improvement. RESEARCH DESIGN: A retrospective cohort study utilizing Veterans Affairs (VA) national administrative data. SUBJECTS: Patients who were evaluated in a VA primary care clinic on at least 1 occasion for CTS and received carpal tunnel release over a 7-year period. MEASURES: We modeled facility-level performance on 2 outcomes: surgical delay (marker of quality) and number of presurgical encounters (utilization) for CTS, and examined association between patient, facility, and care process variables and performance. RESULTS: Among 41,912 Veterans undergoing carpal tunnel release at 127 VA medical centers, the median facility-level predicted probability of surgical delay was 48%, with 16 (13%) facilities having significantly less delay than the median and 13 (10%) facilities having greater delay. The median facility-level predicted number of presurgical encounters was 8.8 visits, with 22 (17%) facilities having significantly fewer encounters and 22 (17%) facilities having more. Care processes had a stronger association with both outcomes than structural variables included in the models. Processes associated with the greatest deviations in predicted delay and utilization included receipt of repeat electrodiagnostic testing, use of 2 or more nonoperative treatments, and community referral outside of VA. CONCLUSIONS: Using CTS as a test case, this study demonstrates the potential to assess presurgical value and identify modifiable care processes associated with presurgical delay and utilization performance.

Impacts of COVID-19 on Appropriate Use of Screening Colonoscopy in a Large Integrated Healthcare Delivery System.

BACKGROUND: Decreasing low-value colonoscopy is critical to optimizing access for high-need patients, particularly in resource-constrained environments such as those created by the COVID-19 pandemic. We hypothesized that rates of screening colonoscopy overuse would decline during COVID compared to pre-COVID due to enhanced procedural scrutiny and prioritization in the setting of constrained access. OBJECTIVE: To characterize impacts of COVID-19 on screening colonoscopy overuse DESIGN: Retrospective national cohort study using Veterans Health Administration administrative data PARTICIPANTS: Veterans undergoing screening colonoscopy in Q4 2019 (pre-COVID) and Q4 2020 (COVID) at 109 endoscopy facilities MAIN MEASURES: Rates of screening colonoscopy overuse KEY RESULTS: 18,376 screening colonoscopies were performed pre-COVID, 19% (3,641) of which met overuse criteria. While only 9,360 screening colonoscopies were performed in Q4 2020, 25% met overuse criteria. Overall change in median facility-level overuse during COVID compared to pre-COVID was 6% (95%CI 5%-7%), with significant variability across facilities (IQR: 2%-11%). Of colonoscopies meeting overuse criteria, the top reason for overuse in both periods was screening colonoscopy performed <9 years after previous screening procedure (55% pre-COVID, 49% during COVID). The largest shifts in overuse category were in screening procedures performed <9 years after prior screening colonoscopy (-6% decline COVID vs. pre-COVID) and screening procedures performed in patients below average-risk screening age (i.e., age <40 (5% increase COVID compared to pre-COVID), age 40-44 (4% increase COVID vs. pre-COVID)). Within facility performance was stable over time; 83/109 facilities changed their performance by <=1 quartile during COVID compared to pre-COVID. CONCLUSIONS: Despite pandemic-related resource constraints and enhanced procedural scrutiny and prioritization in the setting of COVID-related backlogs, screening colonoscopy overuse rates remained roughly stable during COVID compared to pre-COVID, with continued variability across facilities. These data highlight the need for systematic and concerted efforts to address overuse, even in the face of strong external motivating factors.

Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse.

INTRODUCTION: The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS: A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS: 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS: Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.

Workplace Harassment, Cyber Incivility, and Climate in Academic Medicine.

Importance: The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender). Objective: To evaluate academic medical culture, faculty mental health, and their relationship. Design, Setting, and Participants: A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health. Exposures: Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status. Main Outcomes and Measures: Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health. Results: Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis. Conclusions and Relevance: High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.

Type 2 Diabetes Management, Control and Outcomes During the COVID-19 Pandemic in Older US Veterans: an Observational Study.

BACKGROUND: The COVID-19 pandemic required a change in outpatient care delivery models, including shifting from in-person to virtual visits, which may have impacted care of vulnerable patients. OBJECTIVE: To describe the changes in management, control, and outcomes in older people with type 2 diabetes (T2D) associated with the shift from in-person to virtual visits. DESIGN AND PARTICIPANTS: In veterans aged ≥ 65 years with T2D, we assessed the rates of visits (in person, virtual), A1c measurements, antidiabetic deintensification/intensification, ER visits and hospitalizations (for hypoglycemia, hyperglycemia, other causes), and A1c level, in March 2020 and April-November 2020 (pandemic period). We used negative binomial regression to assess change over time (reference: pre-pandemic period, July 2018 to February 2020), by baseline Charlson Comorbidity Index (CCI; > 2 vs. <= 2) and A1c level. KEY RESULTS: Among 740,602 veterans (mean age 74.2 [SD 6.6] years), there were 55% (95% CI 52-58%) fewer in-person visits, 821% (95% CI 793-856%) more virtual visits, 6% (95% CI 1-11%) fewer A1c measurements, and 14% (95% CI 10-17%) more treatment intensification during the pandemic, relative to baseline. Patients with CCI > 2 had a 14% (95% CI 12-16%) smaller relative increase in virtual visits than those with CCI <= 2. We observed a seasonality of A1c level and treatment modification, but no association of either with the pandemic. After a decrease at the beginning of the pandemic, there was a rebound in other-cause (but not hypo- and hyperglycemia-related) ER visits and hospitalizations from June to November 2020. CONCLUSION: Despite a shift to virtual visits and a decrease in A1c measurement during the pandemic, we observed no association with A1c level or short-term T2D-related outcomes, providing some reassurance about the adequacy of virtual visits. Further studies should assess the longer-term effects of shifting to virtual visits in different populations to help individualize care, improve efficiency, and maintain appropriate care while reducing overuse.

Applying User-Centered Design to Develop Practical Strategies that Address Overuse in Primary Care.

INTRODUCTION: Engaging patients and frontline clinicians in re-designing clinical care is essential for improving care delivery in a complex clinical environment. This study sought to assess an innovative user-centered design approach to improving clinical care quality, focusing on the use cases of de-intensifying non-beneficial care within the following areas: (1) de-intensifying diabetes treatment in high-risk patients; (2) stopping screening for carotid artery stenosis in asymptomatic patients; and (3) stopping colorectal cancer screening in average-risk, older adults. METHODS: The user-centered design approach, consisting of patient and patient-clinician charrettes (defined as intensive workshops where key stakeholders collaborate to develop creative solutions to a specific problem) and participant surveys, has been described previously. Following the charrettes, we used inductive coding to identify and categorize themes emerging from the de-intensification ideas prioritized by participants as well as facilitator notes and audio recordings from the charrettes. RESULTS: Thirty-five patients participated in the patient design charrettes, generating 134 unique de-intensification ideas and prioritizing 32, which were then distilled into six patient-generated principles of de-intensification by the study team. These principles provided a starting point for a subsequent patient-clinician charrette. In this follow-up charrette, 9 patients who had participated in an earlier patient design charrette collaborated with 7 clinicians to generate 63 potential de-intensification solutions. Six of these potential solutions were developed into multi-faceted, fully operationalized de-intensification strategies. DISCUSSION: The de-intensification strategies that patients and clinicians prioritized and operationalized during the co-design charrette process were detailed and multi-faceted. Each component of a strategy had a rationale based on feasibility, practical considerations, and ways of overcoming barriers. The charrette-based process may be a useful way to engage clinicians and patients in developing the complex and multi-faceted strategies needed to improve care delivery.

Planning and Reporting Effective Web-Based RAND/UCLA Appropriateness Method Panels: Literature Review and Preliminary Recommendations.

BACKGROUND: The RAND/UCLA Appropriateness Method (RAM), a variant of the Delphi Method, was developed to synthesize existing evidence and elicit the clinical judgement of medical experts on the appropriate treatment of specific clinical presentations. Technological advances now allow researchers to conduct expert panels on the internet, offering a cost-effective and convenient alternative to the traditional RAM. For example, the Department of Veterans Affairs recently used a web-based RAM to validate clinical recommendations for de-intensifying routine primary care services. A substantial literature describes and tests various aspects of the traditional RAM in health research; yet we know comparatively less about how researchers implement web-based expert panels. OBJECTIVE: The objectives of this study are twofold: (1) to understand how the web-based RAM process is currently used and reported in health research and (2) to provide preliminary reporting guidance for researchers to improve the transparency and reproducibility of reporting practices. METHODS: The PubMed database was searched to identify studies published between 2009 and 2019 that used a web-based RAM to measure the appropriateness of medical care. Methodological data from each article were abstracted. The following categories were assessed: composition and characteristics of the web-based expert panels, characteristics of panel procedures, results, and panel satisfaction and engagement. RESULTS: Of the 12 studies meeting the eligibility criteria and reviewed, only 42% (5/12) implemented the full RAM process with the remaining studies opting for a partial approach. Among those studies reporting, the median number of participants at first rating was 42. While 92% (11/12) of studies involved clinicians, 50% (6/12) involved multiple stakeholder types. Our review revealed that the studies failed to report on critical aspects of the RAM process. For example, no studies reported response rates with the denominator of previous rounds, 42% (5/12) did not provide panelists with feedback between rating periods, 50% (6/12) either did not have or did not report on the panel discussion period, and 25% (3/12) did not report on quality measures to assess aspects of the panel process (eg, satisfaction with the process). CONCLUSIONS: Conducting web-based RAM panels will continue to be an appealing option for researchers seeking a safe, efficient, and democratic process of expert agreement. Our literature review uncovered inconsistent reporting frameworks and insufficient detail to evaluate study outcomes. We provide preliminary recommendations for reporting that are both timely and important for producing replicable, high-quality findings. The need for reporting standards is especially critical given that more people may prefer to participate in web-based rather than in-person panels due to the ongoing COVID-19 pandemic.

The Impact of Community Care Referral on Time to Surgery for Veterans With Carpal Tunnel Syndrome.

BACKGROUND: The US Department of Veterans Affairs (VA) enacted policies offering Veterans care in the community, aiming to improve access challenges. However, the impact of receipt of community care on wait times for Veterans receiving surgical care is poorly understood. OBJECTIVES: To compare wait times for surgery for Veterans with carpal tunnel syndrome who receive VA care plus community care (mixed care) and those who receive care solely within the VA (VA-only). RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Veterans undergoing carpal tunnel release (CTR) between January 1, 2010 and December 31, 2016. MEASURES: Our primary outcome was time from primary care physician (PCP) referral to CTR. RESULTS: Of the 29,242 Veterans undergoing CTR, 23,330 (79.8%) received VA-only care and 5912 (20.1%) received mixed care. Veterans receiving mixed care had significantly longer time from PCP referral to CTR (median mixed care: 378 days; median VA-only care: 176 days, P<0.001). After controlling for patient and facility covariates, mixed care was associated with a 37% increased time from PCP referral to CTR (adjusted hazard ratio, 0.63; 95% confidence interval, 0.61-0.65). Each additional service provided in the community was associated with a 23% increase in time to surgery (adjusted hazard ratio, 0.77; 95% confidence interval, 0.76-0.78). CONCLUSIONS: VA-only care was associated with a shorter time to surgery compared with mixed care. Moreover, there were additional delays for each service received in the community. With likely increases in Veterans seeking community care, strategies must be used to identify and mitigate sources of delay through the spectrum of care between referral and definitive treatment.

A Health Systems Ethical Framework for De-implementation in Health Care.

INTRODUCTION: Unnecessary health care not only drive up costs, but also contribute to avoidable patient harms, underscoring an ethical obligation to eliminate practices which are harmful, lack evidence, and prevent spending on more beneficial services. To date, de-implementation ethics discussions have been limited and focused on clinical ethics principles. An analysis of de-implementation ethics in the broader context of the health care system is lacking. METHODS: To better understand the ethical considerations of de-implementation, recognizing it as a health care systems issue, we applied Krubiner and Hyder's bioethical framework for health systems activity. We examine ethics principles relevant to de-implementation, which either call for or facilitate the reduction of low value surgery. RESULTS AND DISCUSSION: From 11 health systems principles proposed by Krubiner and Hyder, we identified the 5 principles most pertinent to the topic of de-implementation: evidence and effectiveness, transparency and public engagement, efficiency, responsiveness, and collaboration. An analysis of de-implementation through the lens of these principles not only supports de-implementation but proves an obligation at the health system level to eliminate low value care. Recognizing the challenge of defining "value," the proposed framework may increase the legitimacy and objectivity of de-implementation. CONCLUSIONS: While there is no single ideal ethical framework from which to approach de-implementation, a health systems framework allows for consideration of the systems-level factors impacting de-implementation. Framing de-implementation as a health systems issue with systems-wide ethical implications empowers providers to think about new ways to approach potential roadblocks to reducing low-value care.

Completing the MISSION: a Blueprint for Helping Veterans Make the Most of New Choices.

The June 6, 2019, implementation of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act commenced a new era in health care for Veterans in which the more than 9 million Veterans who use VA care can now choose community (i.e., non-VA) clinicians or facilities when certain new criteria are met. This expansion of Veterans' health care options could give many Veterans more freedom to decide which settings best meet their individual needs and expectations, and could also lead to unintended consequences for Veterans who do not have all of the information they need to make personalized decisions about VA and community care. In this Perspective article, we recommend initial steps that VA leaders and VA clinicians need to take, and community clinicians should be aware of, in order to ensure that Veterans' expanded health care options translate into improvements in their access and outcomes.

Measures Used to Assess the Impact of Interventions to Reduce Low-Value Care: a Systematic Review.

IMPORTANCE: Studies of interventions to reduce low-value care are increasingly common. However, little is known about how the effects of such interventions are measured. OBJECTIVE: To characterize measures used to assess interventions to reduce low-value care. EVIDENCE REVIEW: We searched PubMed and Web of Science to identify studies published between 2010 and 2016 that examined the effects of interventions to reduce low-value care. We also searched ClinicalTrials.gov to identify ongoing studies. We extracted data on characteristics of studies, interventions, and measures. We then developed a framework to classify measures into the following categories: utilization (e.g., number of tests ordered), outcome (e.g., mortality), appropriateness (e.g., overuse of antibiotics), patient-reported (e.g., satisfaction), provider-reported (e.g., satisfaction), patient-provider interaction (e.g., informed decision-making elements), value, and cost. We also determined whether each measure was designed to assess unintended consequences. FINDINGS: A total of 1805 studies were identified, of which 101 published and 16 ongoing studies were included. Of published studies (N = 101), 68% included at least one measure of utilization, 41% of an outcome, 52% of appropriateness, 36% of cost, 8% patient-reported, and 3% provider-reported. Funded studies were more likely to use patient-reported measures (17% vs 0%). Of ongoing studies (registered trials) (N = 16), 69% included at least one measure of utilization, 75% of an outcome, 50% of appropriateness, 19% of cost, 50% patient-reported, 13% provider-reported, and 6% patient-provider interaction. Of published studies, 34% included at least one measure of an unintended consequence as compared to 63% of ongoing studies. CONCLUSIONS AND RELEVANCE: Most published studies focused on reductions in utilization rather than on clinically meaningful measures (e.g., improvements in appropriateness, patient-reported outcomes) or unintended consequences. Investigators should systematically incorporate more clinically meaningful measures into their study designs, and sponsors should develop standardized guidance for the evaluation of interventions to reduce low-value care.

Variation in Nonsurgical Services for Carpal Tunnel Syndrome Across a Large Integrated Health Care System.

PURPOSE: To evaluate facility-level variation in the use of services for patients with carpal tunnel syndrome (CTS) receiving care in the Veterans Health Administration (VHA). METHODS: A national cohort of VHA patients diagnosed with CTS during fiscal year 2013 was divided into nonsurgical and operative treatment groups for comparison. We assessed the use of 5 types of CTS-related services (electrodiagnostic studies [EDS], imaging, steroid injection, oral steroids, and therapeutic modalities) in the prediagnosis and postdiagnosis periods before any operative intervention at the patient and facility levels. RESULTS: Among 72,599 patients newly diagnosed with CTS, 5,666 (7.8%) received carpal tunnel release within 12 months. The remaining 66,933 (92.2%) were in the nonsurgical group. Therapeutic modalities and EDS were the most commonly employed services after the index diagnosis and had large facility-level variation in use. At the facility level, the use of therapeutic modalities ranged from 0% to 93% in the operative group (mean, 32%) compared with 1% to 67% (mean, 30%) in the nonsurgical group. The use of EDS in the postdiagnosis period ranged from 0% to 100% (mean, 59%) in the operative treatment group and 0% to 55% (mean, 26%) in the nonsurgical group at the facility level. CONCLUSIONS: There is wide facility variation in the use of services for CTS among patients receiving operative and nonsurgical treatment. Care delivered by facilities with the highest and lowest rates of service use may suggest overuse and underuse, respectively, of nonsurgical CTS services and a lack of consideration of individual patient factors in making health care decisions regarding use. CLINICAL RELEVANCE: Surgeons must understand the degree of treatment variability for CTS, comprehend the ramifications of large variation in reimbursement and waste in the health care system, and become involved in devising strategies to optimize hand care across all phases of care.

Midcareer Satisfaction and Likelihood of Leaving Current Position of Former Career Development Awardees.

This study assesses career satisfaction, discrepancies between ideal and expected careers, and likelihood of leaving current positions among former K awardees.

Predictors of Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in a Capitated Payment System.

BACKGROUND & AIMS: Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. METHODS: We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities. RESULTS: The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. CONCLUSIONS: In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors.

Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries.

BACKGROUND: Deintensification of diabetic therapy is often clinically appropriate for older adults, because the benefit of aggressive diabetes treatment declines with age, while the risks increase. OBJECTIVE: We examined rates of overtreatment and deintensification of therapy for older adults with diabetes, and whether these rates differed by medical, demographic, and socioeconomic characteristics. DESIGN, SUBJECTS, AND MAIN MEASURES: We analyzed Medicare claims data from 10 states, linked to outpatient laboratory values to identify patients potentially overtreated for diabetes (HbA1c < 6.5% with fills for any diabetes medications beyond metformin, 1/1/2011-6/30/2011). We examined characteristics associated with deintensification for potentially overtreated diabetic patients. We used multinomial logistic regression to examine whether patient characteristics associated with overtreatment of diabetes differed from those associated with undertreatment (i.e. HbA1c > 9.0%). KEY RESULTS: Of 78,792 Medicare recipients with diabetes, 8560 (10.9%) were potentially overtreated. Overtreatment of diabetes was more common among those who were over 75 years of age and enrolled in Medicaid (p < 0.001), and was less common among Hispanics (p = 0.009). Therapy was deintensified for 14% of overtreated diabetics. Appropriate deintensification of diabetic therapy was more common for patients with six or more chronic conditions, more outpatient visits, or living in urban areas; deintensification was less common for those over age 75. Only 6.9% of Medicare recipients with diabetes were potentially undertreated. Variables associated with overtreatment of diabetes differed from those associated with undertreatment. CONCLUSIONS: Medicare recipients are more frequently overtreated than undertreated for diabetes. Medicare recipients who are overtreated for diabetes rarely have their regimens deintensified.

Overuse of Repeat Upper Endoscopy in the Veterans Health Administration: A Retrospective Analysis.

OBJECTIVES: Americans undergo ∼7 million esophagogastroduodenoscopies (EGDs) annually, and one-third of Medicare beneficiaries undergo a repeat EGD within 3 years. As many as 43% of these repeat EGDs are inappropriate. We aimed to determine the rate of repeat inappropriate EGD within the Veterans Health Administration (VHA), and identify factors associated with repeat EGD. METHODS: We conducted retrospective analyses of Veterans undergoing an index EGD at 159 VHA facilities between 1 January 2003 and 30 June 2007. We excluded Veterans without regular use of VHA for health care or 5 years of follow-up. Appropriateness of repeat EGDs was classified based on diagnostic and procedure codes into three categories: Likely Appropriate, Possible Overuse, and Probable Overuse. The proportion of repeat EGDs in each category was tabulated. Multilevel logistic regression was performed to estimate the impact of patient-level and site-level factors on the odds of repeat EGD. RESULTS: Of the 235,855 included Veterans, 85,690 (36.3%) underwent a repeat EGD within 5 years. Of the repeat EGDs, 42,412 (49.5%) were Likely Appropriate, 35,503 (41.4%) represented Possible Overuse, and 7,756 (9.1%) represented Probable Overuse. Patients with more frequent encounters with primary care providers and access to facilities performing EGD and with greater complexity of services were more likely to receive repeat EGD, regardless of whether the repeat EGD was appropriate or overuse. Women were slightly more likely to undergo repeat EGD in Probable Overuse situations. CONCLUSIONS: Overuse of repeat EGD is common in VHA despite the absence of financial incentives that promote overuse. Efforts are needed to better understand the motivations for overuse and barriers to appropriate use, and to promote appropriate use of repeat EGD.

Perceived Barriers to Implementing Individual Choosing Wisely® Recommendations in Two National Surveys of Primary Care Providers.

BACKGROUND: While some research has examined general attitudes about efforts to reduce overutilization of services, such as the Choosing Wisely® (CW) initiative, little data exists regarding primary care providers' attitudes regarding individual recommendations. OBJECTIVE: We sought to identify whether particular CW recommendations were perceived by primary care providers as difficult to follow, difficult for patients to accept, or both. DESIGN: Two national surveys, one by mail to a random sample of 2000 U.S. primary care physicians in November 2013, and the second electronically to a random sample of 2500 VA primary care providers (PCPs) in October-December 2014. PARTICIPANTS: A total of 603 U.S. primary care physicians and 1173 VA primary care providers. Response rates were 34 and 48 %, respectively. MAIN MEASURES: PCP ratings of whether 12 CW recommendations for screening, testing and treatments applicable to adult primary care were difficult to follow and difficult for patients to accept; and ratings of potential barriers to reducing overutilization. KEY RESULTS: For four recommendations regarding not screening or testing in asymptomatic patients, less than 20 % of PCPs found the CW recommendations difficult to accept (range 7.2-16.6 %) or difficult for patients to follow (12.2-19.3 %). For five recommendations regarding testing or treatment for symptomatic conditions, however, there was both variation in reported difficulty to follow (9.8-32 %) and a high level of reported difficulty for patients to accept (35.7-87.1 %). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists. CONCLUSIONS: While PCPs found many CW recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. Overcoming PCPs' perceptions of patient acceptability will require approaches beyond routine physician education, feedback and financial incentives.

Diagnostic Testing Requested Before Surgical Evaluation for Carpal Tunnel Syndrome.

PURPOSE: We sought to evaluate how often physicians who perform carpal tunnel release in the state of Michigan routinely request electrodiagnostic studies (EDS) or other diagnostic tests prior to an initial consultation and whether provider or practice characteristics had an influence on requirements for preconsultation diagnostic tests. METHODS: Through online data sources, we identified 356 providers in 261 practices throughout the state of Michigan with profiles confirming hand surgery practice or surgical treatment of carpal tunnel syndrome (CTS). We recorded American Society for Surgery of the Hand (ASSH) membership, teaching facility status, practice size, and primary specialty for each provider. Using a standardized telephone script, 219 providers were contacted by telephone to determine whether any diagnostic tests were needed before an appointment. Using multivariable logistic regression, we evaluated the relationship between the requirement for preconsultation testing and surgeon and practice characteristics. RESULTS: Among the 134 providers who were confirmed to perform carpal tunnel release, 57% (n = 76) required and 9% (n = 12) recommended a diagnostic test prior to the initial consultation. Of the 88 physicians who required/recommended testing, 85% (n = 75) requested EDS, 22% (n = 19) requested magnetic resonance imaging, 13% (n = 11) requested a computed tomography scan, and 9% (n = 8) requested an x-ray. Patients were asked to have multiple studies by 19 (22%) of the 88 surgeons who requested/recommended testing. In the multivariable analysis, ASSH membership, size of practice, and teaching facility status did not have a significant relationship with the requirement for preconsultation testing. CONCLUSIONS: Most surgeons who treat CTS in the state of Michigan routinely request EDS before evaluation, rather than reserving the test for cases in which the diagnosis is unclear. CLINICAL RELEVANCE: In the quest for high-value care, providers must consider whether the benefit of diagnostic tests for CTS likely outweighs the costs, inconvenience, and potential for treatment delay.